Promoting Employee Voice and
Upward Communication in
Healthcare: The CEO’s Influence
Kimberly Adelman, PhD; project manager, Stryker Performance Solutions; adjunct
faculty, Colorado Technical University
EXECUTIVE SUMMARY
As noted by the Institute of Medicine (2004), a lack of critical upward feedback in
the hospital setting has adverse effects on direct patient care and health outcomes.
Employees are oftentimes reluctant to share information, as those above them
might interpret the information to be negative or threatening. Leaders then may
make important decisions based on assumptions or inaccurate feedback. The situation is especially significant in the healthcare setting, where hierarchical structures
(Nembhard and Edmondson 2006), divisions between administrators and clinicians,
and lack of collaboration across teams reinforce employee silence and undermine
organizational learning (Ramanujam and Rousseau 2006).
Chief executive officers play a key role in developing a culture that fosters
employee voice and upward communication (Ashford, Sutcliffe, and Christianson
2009). Hospitals winning performance excellence awards, such as those utilizing
the Malcolm Baldrige National Quality Award Criteria for Performance Excellence,
present a model of high performance with demonstrated results. The purpose of this
study was to understand specific CEO behaviors and actions promoting employee
voice and upward communication in performance excellence award­–winning healthcare organizations.
Results suggested the award-winning CEOs facilitated employee voice by being
approachable, mainly achieved through their regular presence throughout the
organization. By being consistently visible and available to employees these CEOs
fostered relationships, built trust, and promoted open communication. Leaders in
the study created a cultural focus on continuous improvement largely built around
transparency of information, particularly looking for the bad news from their
employees. Voice invitation and positive voice response from leaders reinforced that
critical upward feedback is not only welcome, but expected.
For more information on the concepts in this article, please contact Dr. Adelman
at ksadelman@gmail.com.
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
133
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
J o u r n al o f H ea l th c a re M a n a g em en t 5 7 : 2 M arc h / April 2012
INTRODUCTION
In the healthcare setting, feedback
from all levels of the organization is
necessary to make improvements and
prevent life-threatening errors (IOM
2004; Tucker and Edmondson 2003).
While most leaders agree on the value
of upward communication and its
role in organizational effectiveness,
many organizations still struggle with
upward communication of both negative and positive information (Milliken, Morrison, and Hewlin 2003).
Employee voice, defined in this study
as the discretionary provision of information intended to improve organizational functioning to someone with
the authority to act (Detert and Burris
2007), is necessary if leaders are to
receive honest upward feedback from
individuals throughout all levels of
the institution.
Chief executive officers (CEOs) play
a key role in developing a culture that
fosters employee voice and upward
communication (Ashford, Sutcliffe, and
Christianson 2009). Having a culture
of safety increases the chances employees will take positive risks and speak
candidly. For organizational success,
healthcare leaders must develop a culture in which employees realize that a
sense of safety exists (Valadares 2004).
Findings from studies about psychological safety and communication
in the healthcare environment have
not articulated the actual leadership
behaviors and practices necessary to
create a culture of safety other than
encouraging and training employees to
speak up (Valadares 2004; Nembhard
and Edmondson 2006). McAlearney
(2006) notes that healthcare organizaPhotocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
tions pay little attention to improving
management practices, which increases
the likelihood of repeating previous
mistakes. The purpose of this study
was to understand CEO behaviors and
actions that promote employee voice
and upward communication in performance excellence award–winning
healthcare organizations, addressing a
gap in current literature.
The research questions guiding
this study were: (1) How do CEOs
of performance excellence award–
winning healthcare organizations
foster employee voice and upward
communication of both positive and
negative information in their organization? (2) How do CEOs of performance
excellence award–winning healthcare
organizations approach communication? (3)What can researchers learn
from the CEO approaches?
METHODOLOGY
Study Design
A phenomenological collective,
or multiple, case study approach
(Moustakas 1994) was employed. Phenomenological research utilizes data
collected from several persons who
have familiarity with the phenomenon under study in order to capture
their various points of view (Creswell
2007). The purpose of a case study is
to obtain detailed descriptions and
interpretations (Stake 1995). The lived
experiences of hospital employees in
regard to employee voice and upward
communication within their performance excellence award–winning
hospital was the phenomenon investigated in this case study.
134
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
P r o m o ti n g E m p l o y ee V o i c e a n d Upward Com m u n ic ation in H e al th c are
CEOs whose healthcare organizations had received either the MBNQA
or state-level Baldrige award within
the past seven years served as the four
cases. Two national-level MBNQA and
two state-level performance excellence
award–winning hospitals participated
in the study (see Exhibit 1 for case
demographics). The focus on four
cases allowed robust data collection
and analytic conclusions (Yin 2008)
while keeping the scope of the study
manageable. Emphasis was on the
quality of data collection and analysis
versus the quantity, as more cases and
more interviews would not necessarily mean the study is more scientific
(Kvale 1996). Purposeful sampling
(Passmore and Baker 2005) of only
performance excellence award­–winning health organizations specifically
addressed the research questions,
assuming that performance excellence
award winners might be more effective
at communicating than non-winners
(Calhoun, Griffith, and Sinioris 2007;
Griffith and Patullo 2009).
Data Collection
Document review of the participant’s
MBNQA or state award application and
20 semi-structured telephone interviews
with members of the organizations
provided data for the study. Information documented under the Senior
Leadership and Workforce Engagement
categories of the organization’s award
application (NIST 2009) was collected
utilizing a document review summary
form, specifically answering the following questions from the Health Care
Criteria for Performance Excellence
(NIST 2009):
• How do senior leaders communicate
with and engage the entire workforce?
(p. 7)
• How do senior leaders encourage
frank, two-way communication
throughout the organization? (p. 7)
• How do senior leaders foster an
organizational culture characterized
by open communication, highperformance work, and an engaged
workforce? (p. 18)
EXHIBIT 1
Demographics of Studied Hospitals
Number of Employees
Type of Organization
CEO Tenure
Case 1
14,000
Not-for-profit
Regional system
4 years
Case 2
4,000
Locally owned, not-for-profit
Regional hub
7 years
Case 3
2,080
Governmental, not-for-profit
Community hospital
5½ years
Case 4
5,200
Not-for-profit
Regional system
4 years
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
135
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
J o u r n al o f H ea l th c a re M a n a g em en t 5 7 : 2 M arc h / April 2012
In addition to document review,
interviews were conducted with individuals at different levels within each
organization, from the CEO to a frontline nurse, to capture perspectives from
individuals throughout the organization. Interviewees from clinical service
areas, particularly frontline nurses,
were targeted to participate because the
Institute of Medicine (2004) noted that
silence of nurses contributes to medical
errors and compromises patient safety.
Five interviews took place from each
of the four participating performance
excellence award–winning healthcare
organizations, for 20 interviews in all.
Interviewees included (a) the CEO,
(b) the Baldrige lead for the hospital,
(c) a director of a clinical services area,
(d) a frontline manager or supervisor
of a clinical services area, and (e) a
frontline nurse. All interviews followed
a semi-structured interview guide and
were recorded for later transcription.
Interviewees reviewed and checked their
transcripts to ensure information in the
transcript was an accurate representation
of their perspectives.
from multiple cases are typically more
robust than those from a single case,
the study examined four cases, performing analysis and drawing conclusions
first within each and then across all of
the cases.
ATLAS.ti 6 analytical software was
used to assist with qualitative coding and data analysis. In case study
research, the search for meaning consists of identifying patterns in the data
(Stake 1995). Similarly, phenomenological reduction organizes textural
meanings and patterns into themes.
Because participants spoke about their
experiences, actions, behaviors, and perceptions using their own words, codes
were assigned from words and phrases
used by the participants. An a priori list
of initial codes helped guide the coding
process; however, inductive development of codes continued as necessary
throughout the study to capture all relevant data (Cres­well 2007). Coding and
analysis of interview transcripts, field
notes, and document review data was
completed to identify salient categories,
patterns, and themes.
Data Analysis
The intention of case study research is
not generalization but rather addressing
a particular case and knowing it well
through an emphasis on uniqueness
and understanding (Stake 1995). In a
multiple case study, cases are purposefully chosen using replication logic to
predict either similar or contrasting
results. Quantitative sampling logic,
such as that used when choosing multiple respondents in a survey or multiple
subjects within an experiment, is not
appropriate (Yin 2008). Because results
R E S U LT S
Interview participants described important information they communicated
upward to senior leaders in their organizations. Across all four cases, information communicated upward consisted
of both positive and negative feedback.
Exhibit 2 provides a complete list of
topics generally communicated upward
by interview participants and in which
of the four cases the topic was identified
as being present. Participants always
spoke about first conveying concerns
or issues with patients, employees, or
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
136
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
P r o m o ti n g E m p l o y ee V o i c e a n d Upward Com m u n ic ation in H e al th c are
EXHIBIT 2
Participant-Identified Important Information Communicated Upward to Leaders
Identified in Case #
Information Type
1
2
3
4
X
Complaints
X
Cultural concerns
Employee concerns
X
Employee recognition
X
Employee satisfaction/morale
X
X
Ideas for change/improvement
X
X
X
Legal issues
X
Medical staff status
Patient-care issues
X
X
Patient satisfaction
X
X
Physician satisfaction
X
X
X
X
X
X
Quality data/information
Safety issue/events
X
X
Staff achievement/certification
X
X
X
X
Staffing issues
X
Status with operating plan/goals
X
Things that are working well
physicians prior to relaying upward any
positive feedback. This demonstrated
an emphasis on patient care, physician
satisfaction, and safety from the participants at these organizations.
RQ1: How are CEOs of performance
excellence award–winning healthcare
organizations fostering employee voice
and upward communication of both
positive and negative information in
their organization?
Visibility and Approachability
Visibility of the CEO and other senior
leaders emerged as a theme in the
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
X
study. All CEOs were visible and present in their organization on a regular
basis, through rounding, employeeleader forums, or meetings with
employees. Their presence allowed
employees to know the person who
was the CEO versus the CEO simply
being a name or someone they read
about but never saw. Face-to-face
interactions with the CEO and other
senior leaders helped develop relationships and trust. Employees appreciated
seeing and knowing the CEO, and
because employees saw the leaders on
a regular basis they felt more comfortable talking to them.
137
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
J o u r n al o f H ea l th c a re M a n a g em en t 5 7 : 2 M arc h / April 2012
Being present and interacting with
employees gave the CEOs a chance to
model their expectations with regard to
frank, two-way communication. During
face-to-face interactions with employees
CEOs answered questions as honestly
as possible, helping to set the tone for
ongoing communication and building
trust with employees. Being visible also
gave the CEOs opportunities to actively
listen to employees and invite feedback
in the comfort of the employees’ own
work environments.
Interview participants in Case 4
emphasized the approachability of their
CEO. Similar to visibility, approachability revolved strongly around regular
face-to-face communication with the
CEO; however, in this case, the CEO
also placed emphasis on employees
feeling welcome to come to administration and to approach any of the senior
leaders at any time. He made himself
approachable by connecting personally
with individual employees; learning
about their families, communicating
his genuine concern for their well-being,
and offering them his assistance. He
also held other leaders accountable to
the same standard of open, relational
leadership behavior.
Culture
All CEOs in the study demonstrated a
focus on their organization’s culture.
Similar in all four cases was a culture
of continuous improvement, guided
by the organization’s mission, vision,
values, and established employee
behavior standards. The CEOs believed
the organization could achieve
improvements and excellence only
by fully engaging employees for ideas
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
and expertise. The concentration on
continuous improvement gave employees permission to speak up about bad
news, issues, or concerns. In fact, it was
an expectation in all cases that employees would speak up to leaders with
both positive and negative information.
Leaders openly addressing bad news
helped promote a transparent culture
in which critical upward feedback was
not only accepted but expected. As one
interviewee described:
Through solicitation of adverse events
each week and reporting adverse or
negative information upward to the
board . . . that we are comfortable taking
something we don’t perform well at,
putting it on a system scorecard and
looking at it every month and talking
about it every quarter . . . when leaders
are willing to stand in there for that, then
employees see it’s okay not to be perfect.
All CEOs were also cognizant about
providing a response to all employees
who asked questions or voiced concerns
in order to encourage continued upward
feedback. When employees saw actions
or changes evolving from their input,
they felt their voices counted, which
reinforced speaking up. In all cases,
the CEO initially set the expectation
for employee voice at new employee
orientation.
Formal Communication Strategies
All hospitals in the study utilized multiple formal communication strategies
to promote two-way communication
between employees and senior leaders
(see Exhibit 3). The formal reporting
structure of the organization was the
foremost strategy used by employees
to provide critical upward feedback
138
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
P r o m o ti n g E m p l o y ee V o i c e a n d Upward Com m u n ic ation in H e al th c are
EXHIBIT 3
Formal Approaches to Communication
Ad hoc focus groups
Compliance hotlines
Cross-functional committees
Department/unit orientation
Departmental meetings
Departmental retreats
Electronic performance scorecards
Electronic idea-submission forums
Employee-leader forums (town hall)
Employee culture surveys
Employee luncheons
Employee opinion surveys
Employee recognition celebrations
HR-led focus groups
Internal newsletters
Intranet website
Knowledge boards
Leadership meetings
Leadership retreats
Leadership education
Learn and lead programs
Management team meetings
Medical staff meetings
Mission, vision, values team
Monthly CEO report
New employee orientation
One-on-one meetings/luncheons
Performance excellence teams
Process improvement teams
Reporting hierarchy
Rounding
“Round up” reviews
Service line meetings
Shared governance structure
Steering committees
Suggestion boxes
Systems operation meetings
Unit-based councils
Volunteer satisfaction surveys
to leadership. When asked how they
communicated important information
upward in their organization, all interview participants responded that they
would talk with their direct supervisor
first and then move up the hierarchy
as needed. All CEOs were aware the
hierarchy could potentially help or
hinder frank, open communication.
They respected the reporting structure
but were also available for employees
to communicate with directly.
Regular leadership and departmental meetings took place as a major
means of information exchange across
all cases. Steering committees, crossfunctional teams, and process improvement committees were also used. All
participants discussed using meeting
and committee structures as a main
avenue to voice concerns and to communicate upward to senior leaders.
The CEO was visible for all employees primarily through rounding in all
four cases. Even though the tone and
conversations during rounding were
fairly informal, the schedule and structure was formalized to ensure compliance and accountability. Leaders used
rounding logs in at least two of the
four cases as a tool to track trends, track
employee recognition, and follow up
on issues. All CEOs discussed rounding
as their primary means for soliciting
upward feedback and made it a priority
in their regular schedule.
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
139
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
J o u r n al o f H ea l th c a re M a n a g em en t 5 7 : 2 M arc h / April 2012
All CEOs utilized employee-leader
forums, sometimes called town hall
meetings, to communicate directly with
employees. The structure of the forums
was nearly the same across all cases,
with the CEO or other senior leader presenting information to the group first.
However, the CEOs viewed as the most
important part of the forum the last
segment, in which the floor was opened
to questions and comments from the
employees. This was an opportunity to
solicit critical upward feedback, address
rumors and employee concerns, and
answer questions in a transparent way.
Secondary to rounding, employees highlighted these forums as the main way
they communicated face-to-face with
their CEO.
All cases employed some form of
computerized communication and
feedback repository for employees to
submit questions or concerns directly
to senior leaders. The leadership team
reviewed ideas, questions, or comments
submitted electronically by employees through these systems regularly.
In addition, all cases in the study used
employee opinion surveys. However,
Case 2 was the only one to specifically
utilize employee cultural surveys as a
method for soliciting employee feedback and monitoring staff satisfaction
and engagement. The CEO had a goal
of 75 percent employee participation
in the employee opinion survey, with
a component of the employee bonus
structure linked to achieving that goal.
The rationale behind the high participation target was that without enough
employee input, the organization might
work toward improving a small sample
of items that were the concerns of only
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
a few employees rather than addressing
the concerns of the majority.
Informal Communication Strategies
Informal communication strategies also
played an important role in facilitating employee voice by providing more
relaxed ways for employees to express
their ideas. All interview participants
utilized e-mail or telephone calls to ask
questions or convey important information to leaders. The CEO and leadership team members in all four cases
had open-door policies, so employees
could stop them in the hallway, drop
by their offices, or schedule meetings
when they needed to discuss something.
Other informal approaches included
meals that the CEO and leadership
team members served staff, such as the
grill days demonstrated in Case 2, or
CEO-frontline employee breakfasts and
luncheons utilized in cases 2, 3, and 4.
Unique to Case 1 was the use of podcasts, blogging, and other social media,
including Facebook and Twitter, to
communicate in the variety of ways that
people may prefer to receive or exchange
information.
RQ2: How do performance excellence
award­–winning CEOs approach
communication?
All CEOs highly valued employee voice
and the knowledge that each employee
brought to the organization. There
was consensus among the CEOs that
communication was a challenge in the
healthcare environment that required
ongoing attention and that new and
varied approaches would always be
essential. The CEOs believed employees
were experts about what was happening
140
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
P r o m o ti n g E m p l o y ee V o i c e a n d Upward Com m u n ic ation in H e al th c are
[they are], then it builds over time.”
These CEOs used transparency and trust
to create a culture of safety so employees
would be comfortable speaking up.
In addition to their own behaviors,
the CEOs understood the important
roles of other leaders in the organization for hindering or facilitating frank,
two-way communications. The CEOs
focused on developing leaders all the
way down to frontline supervisors
through education and training, and
they expected those leaders to develop
open, honest communication with the
employees for whom they were responsible. The CEOs’ approach to communication focused on the entire leadership
force through setting expectations and
holding all leaders accountable to standards for communication.
in the organization and emphasized
the need to tap into that information.
They were relational and collaborative in their approaches and frequently
solicited feedback from employees
throughout the organization. The CEO
from Case 4 summed up the overall
approach when he stated, “And really,
the employees have the pulse of the
organization, and if as leaders we are
not listening to them, we are missing
the boat.”
All CEOs modeled the communication behaviors expected from their
employees. It was important to all of
them to set an example, knowing it
would set the tone for the entire organization, and they all spent significant
time either rounding throughout their
organizations or in small groups or oneon-one sessions with employees. This
sometimes meant being in uncomfortable situations and hearing things they
might not want to hear. As the CEO of
Case 1 stated:
RQ3: What can we learn from the
CEO approaches?
A framework of key elements of leadership focus promoting employee voice
and upward communication emerged
from the data analysis (see Exhibit 4).
Each of the four themes—establishing
a culture of excellence, creating voice
opportunity, reinforcing voice instrumentality, and the removal of risks and
costs by leaders—positively influenced
employee voice in the study.
Executives, it can be easy to isolate
yourself and sometimes it can be easier
not to be out there on the front line
hearing the issues and participating in
finding the solutions and addressing
issues. I just think you’ve got to be
present and you’ve got to be committed
and you’ve got to be concerned about
all people.
The CEOs attached extreme importance to having all employees know
who they were, and it was crucial to
answer employee questions truthfully
to develop trust. As the Case 3 CEO
articulated, “People may be a little reluctant to ask at the beginning, but if you
answer the questions in the most transparent way possible, regardless of what
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
Voice Opportunity
Leaders created voice opportunity
(Ashford, Sutcliffe, and Christianson
2009) through visibility and approachability and the use of both formal and
informal communication channels.
Visibility-promoting actions included
rounding and face-to-face conversations with employees via hallway
141
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
J o u r n al o f H ea l th c a re M a n a g em en t 5 7 : 2 M arc h / April 2012
EXHIBIT 4
Leadership Influence on Employee Voice
conversations, open forums, or informal meals and celebrations. Modeling
transparent communication and talking about things that were not going
well reinforced the act of speaking up
as welcome and expected.
Culture and Voice Instrumentality
A high degree of voice instrumentality
(Ashford Sutcliffe, and Christianson
2009) was achieved through a culture
of voice invitation and positive voice
response. The CEO and other leaders interacted with employees often to
actively solicit comments, and because
leaders asked employees for input on a
regular basis, employees felt comfortable voicing their concerns. Positive
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
voice response from leaders included
taking action on employee suggestions and also providing feedback to
employees when leaders did not act on
suggestions. The consistent response
from leaders demonstrated employee
voice had an impact on decisions and
patient care.
Risks and Costs
According to Chiaburu, Marinova, and
Van Dyne (2008), employees must
experience a sense of psychological
safety before they will consider exercising their voice and speak up to leaders
in the organization. A climate of safety
was constructed by the CEOs through
building relationships and establishing
142
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
P r o m o ti n g E m p l o y ee V o i c e a n d Upward Com m u n ic ation in H e al th c are
trust and by advancing the expectation
that every employee’s job was to speak
up with concerns or ideas for improvement. Relationships and trust develop
when people work together over time.
The hospitals studied demonstrated
relatively high average tenure across their
employee population. Hiring and retaining the right employees was an area
discussed by the CEOs, who pointed out
that as people worked together longer
they became more comfortable communicating negative or bad news to each
other. The climate of safety created in the
study cases allowed individuals to take
interpersonal risks with regard to communicating information to leaders.
DISCUSSION
Patient care concerns, safety issues or
events, and physician satisfaction issues
were the most frequent items communicated upward to senior leaders in
the study. Common communication
of negative issues was somewhat unexpected, as it conflicted with Tourish
and Robson’s (2003) findings in which
upward feedback in the healthcare
setting was mostly absent and when it
did occur was overly positive. Earlier,
Milliken, Morrison, and Hewlin (2003)
also indicated that most employees
were afraid to speak up about problems with organizational processes and
performance or to offer suggestions for
improvement. The current case study
found the opposite, with employees
comfortable speaking up with negative
news or issue-focused information to
leaders in their hospitals. Employees
in the study felt they were supporting
leaders by giving them notice of any
bad news or current issues. Participants
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
attributed their comfort speaking up to
the organizations’ cultures of continuous improvement and the ease from
routinely seeing and interacting with
the CEO and other senior leaders.
Consistent with the findings of
Valadares (2004) and Nembhard and
Edmondson (2006), employees in the
study emphasized the importance of
the CEO and senior leaders in setting
the culture of safety for communication.
The positive response to voice exhibited
in all cases reinforced to employees that
they were safe in speaking up with bad
news as well as good news. Because
the CEOs were transparent and actively
solicited employee voice, employees
regularly provided critical upward
feedback. Employees felt listened to
and respected, especially when the CEO
proactively sought out their input.
CEOs in the study found great value
in being visible, present, and available
for all employees. The CEOs pointed
out it would be easy to stay in their
offices, isolate themselves, and not hear
things that might be difficult to hear;
however, they emphasized the need for
feedback from employees as necessary
for organizational success. Similar to
prior research describing the benefits of
managing by walking around (Peters
and Austin 1985), CEOs and other
leaders spent a significant amount of
time out in the hospital soliciting input
from staff. In an extension of managing
by walking around, providing timely
feedback to each employee who asked
a question or provided a suggestion
was the utmost priority to the CEOs in
the study. It was important for senior
leadership to take action or provide
feedback on employee suggestions to
143
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
J o u r n al o f H ea l th c a re M a n a g em en t 5 7 : 2 M arc h / April 2012
demonstrate that the employee’s voice
had an impact.
The goal of each CEO was to build
relationships with employees, find out
what was going on in the organization,
and identify opportunities for improvement. Through their routine presence,
employees knew the CEO and other
senior leaders. Knowing the CEO made
it easier for employees to speak up with
ideas. The finding was consistent with
a recent study by Liu, Zhu, and Yang
(2010), which found employees more
likely to voice their thoughts toward a
target with whom they strongly identified. Sobo and Sadler (2002) also
described how regular face-to-face
interactions with the CEO built trust
and opened a flow of information to
which the CEO might not have otherwise had access.
Participants in the study used
the formal reporting hierarchy of the
organization as their primary means of
communicating information upward.
Challenges with power and status
differences (Morrison and Rothman
2009) or divisions between clinicians
and administrators (Ramanujam and
Rousseau 2006) were not strongly evident in any of the cases. Bidirectional
information flow among different
levels of the organization was facilitated through the hierarchy, through
either conversations with direct supervisors or formal meeting structures.
CEOs respected the reporting structure
but offered em­ployees opportunities
to speak directly with them and other
leaders as needed. Realizing every manager and supervisor within the hospital
could either foster or hinder open communication, CEOs provided ongoing
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
support and leadership development
in the areas of conflict resolution and
communication for all supervisors.
The CEOs set expectations for speaking
up at new employee orientation and
held all leaders, down to the frontline
supervisors, accountable for creating a
culture of safety.
Argyris (1986) noted that consistency within leaders’ espoused values,
words, and actions reduced defensive
routines. Ashford, Sutcliffe, and Christianson (2009) described the constancy
of leader behavior and leaders doing
what they say they will do as reducing communication barriers caused by
power and status differences among
individuals in an organization. Findings
from the current study were congruent
with the previous literature. The CEOs
were keenly aware of the importance of
modeling expected behavior, especially
through consistency of their words
and actions. Fostering of frank, twoway communication occurred mainly
through transparency when answering
employee questions.
L I M I TAT I O N S A N D
R E C O M M E N D AT I O N S F O R
FUTURE RESEARCH
The stated research questions bound
the scope of the study to address only
CEO behaviors facilitating employee
voice and upward communication. No
questions addressed specific leadership
style of the studied CEOs, leaving an
opportunity for future research. The
small number of cases studied may limit
the ability to generalize results across
the larger population of all performance
excellence award winners, other healthcare organizations, or organizations
144
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
P r o m o ti n g E m p l o y ee V o i c e a n d Upward Com m u n ic ation in H e al th c are
outside of the healthcare industry. However, the use of multiple cases was put
into place to produce more compelling
and robust results than would a single
case study design (Yin 2008). A similar
study with non-award-winning hospitals
could be conducted to compare CEO
communication approaches found in
this study and to determine if there is a
positive correlation between the CEO’s
encouragement of employee voice and
organizational performance.
While the study identified four
themes of CEO approaches to promoting employee voice, it is unclear if all
four areas influence employee voice to
the same degree, if they all need to be
present, or if each area can individually influence employee voice alone.
Research specifically examining the
relationships between CEO approaches
toward culture, voice opportunity, voice
instrumentality, and risk and costs
affecting the psychological processes of
employee voice may provide additional
insight and implications.
Interview participants may not have
been representative of their entire peer
group as they were chosen to participate
in the study by the Baldrige lead and
CEO of the hospital. Results might have
been altered with a different sample of
interview participants. The average tenure for participants was 14 years, with
only one employee interview participant
being at the current organization less
than three years. Employee interview
participants who were new employees
might have produced different results.
Studies to determine if employees in
their first year of service feel safe speaking up with ideas and concerns could
produce valuable results, as could
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
investigating what helps employees
in their first year of employment feel
comfortable communicating both negative and positive information upward,
especially for organizations with high
turnover rates.
The importance of senior leaders’
presence in new employee orientation
to set the expectation for open, upward
communication was touched upon
in the findings of the study. However,
additional research into specific practices during the orientation and new
hire process, such as how expectations
for speaking up and voicing concerns
are established, might result in more
specific findings.
Employees consistently used the
hierarchical structure of the hospitals
to communicate information upward
to senior leaders. Research exploring
this avenue of communication could
provide answers to important questions
such as the following:
• Do direct supervisors consistently
communicate employee feedback
upward to senior leaders, or is
employee feedback filtered?
• What actions and behaviors are
the supervisors taking to facilitate
employee voice?
• What communication strategies,
formal or informal, are most effective
for supervisors to receive information
from below and to relay information
upward?
CONCLUSION
Patterns and nuances of CEO behaviors and actions promoting successful
upward communication appeared in
this study. Findings provided detail to
145
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
J o u r n al o f H ea l th c a re M a n a g em en t 5 7 : 2 M arc h / April 2012
assist scholars and practitioners in better understanding how to address the
challenges surrounding upward feedback and systematic communications in
the healthcare setting, highlighting the
importance of CEOs being approachable and physically present throughout
the organization as a key factor of facilitating employee voice.
ACKNOWLEDGEMENT
The author would like to thank Dr. Toni
Buchsbaum Greif, Dr. Cortis (Mac)
McGuire, and Dr. Karen Bammel for
their contributions to the study.
REFERENCES
Argyris, C. 1986. “Reinforcing Organizational
Defensive Routines: An Unintended
Human Resources Activity.” Human
Resource Management 25 (4): 541–55.
Ashford, S. J., K. M. Sutcliffe, and M. K. Christianson. 2009. “Speaking Up and Speaking
Out: The Leadership Dynamics of Voice
in Organizations.” In Voice and Silence in
Organizations, edited by J. Greenberg and
M. S. Edwards, 177–201. Bingley, UK:
Emerald Group.
Calhoun, G., J. Griffith, and M. Sinioris. 2007.
“The Foundation of Leadership in Baldrige
Winning Organizations.” Bulletin of the
National Center of Healthcare Leadership.
Supplement to Modern Healthcare 37:
379–99.
Chiaburu, D. S., S. V. Marinova, and L. Van
Dyne. 2008. “Should I Do It or Not? An
Initial Model of Cognitive Processes Predicting Voice Behaviors.” In Citizenship in
the 21st Century, edited by L. T. Kane and
M. R. Poweller, 127–53. New York: Nova.
Creswell, J. W. 2007. Qualitative Inquiry and
Research Design: Choosing Among Five Traditions, 2nd ed. Thousand Oaks, CA: Sage.
Detert, J. R., and E. R. Burris. 2007. “Leadership
Behavior and Employee Voice: Is the Door
Really Open?” Academy of Management
Journal 50 (4): 869–84.
Griffith, J. R., and A. Pattullo. 2009. “Finding
the Frontier of Hospital Management.”
Journal of Healthcare Management 54 (1):
57–73.
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
Institute of Medicine (IOM). 2004. Keeping Patients Safe: Transforming the Work
Environment of Nurses. Washington, DC:
National Academies Press.
Kvale, S. 1996. Interviews: An Introduction to
Qualitative Research Interviewing. Thousand
Oaks, CA: Sage.
Liu, W., R. Zhu , and Y. Yang. 2010. “I Warn
You Because I Like You: Voice Behavior,
Employee Identifications, and Transformational Leadership.” Leadership Quarterly 21
(1): 189–202.
McAlearney, A. S. 2006. “Leadership Development in Healthcare: A Qualitative Study.”
Journal of Organizational Behavior 27 (7):
967–82.
Milliken, F. J., E. W. Morrison, and P. F.
Hewlin. 2003. “An Exploratory Study of
Employee Silence: Issues That Employees
Don’t Communicate Upward and Why.”
Journal of Management Studies 40 (6):
1453–1476.
Morrison, E. W., and N. B. Rothman. 2009.
“Silence and the Dynamics of Power.” In
Voice and Silence in Organizations, edited
by J. Greenberg and M. S. Edwards, 111–
34. United Kingdom: Emerald Group.
Moustakas, C. 1994. Phenomenological Research
Methods. Thousand Oaks, CA: Sage.
National Institute of Standards and Technology (NIST). 2009. 2009–2010 Health
Care Criteria for Performance Excellence.
www.nist.gov/baldrige/publications/
upload/2009_2010
_HealthCare_Criteria.pdf.
Nembhard, J. A., J. A. Alexander, T. J. Hoff, and
R. Ramanujam. 2009. “Why Does Quality
in Health Care Continue to Lag? Insights
from Management Research.” Academy of
Management Perspectives 23 (1): 24–42.
Nembhard, I. M., and A. C. Edmondson. 2006.
“Making It Safe: The Effects of Leader
Inclusiveness and Professional Status on
Psychological Safety and Improvement
Efforts in Health Care Teams.” Journal of
Organizational Behavior 27 (7): 941–66.
Passmore, D. L., and R. M. Baker. 2005. “Sampling Strategies and Power Analysis.” In
Research in Organizations: Foundations and
Methods of Inquiry, edited by R. A. Swanson
and E. F. Holton, III, 45–55. San Francisco, CA: Berrett-Koehler.
Peters, T., and N. Austin. 1985. “MBWA (Managing by Walking Around).” California
Management Review 28 (1): 9–34.
146
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
P r o m o ti n g E m p l o y ee V o i c e a n d Upward Com m u n ic ation in H e al th c are
Ramanujam, R., and D. M. Rousseau. 2006.
“The Challenges Are Organizational, Not
Just Clinical.” Journal of Organizational
Behavior 27: 811–27.
Sobo, E. J., and B. L. Sadler. 2002. “Improving Organizational Communication and
Cohesion in a Health Care Setting through
Employee-Leadership Exchange.” Human
Organization 61 (3): 277–87.
Stake, R. E. 1995. The Art of Case Study Research.
Thousand Oaks, CA: Sage.
Tourish, D., and P. Robson. 2003. “Critical
Upward Feedback in Organisations:
Processes, Problems and Implications for
Communication Management.” Journal
of Communication Management 8 (2):
150–67.
Tucker, A. L., and A. C. Edmondson. 2003.
“Why Hospitals Don’t Learn from Failures:
Organizational and Psychological Dynamics That Inhibit System Change”. California
Management Review 45 (2): 55–72.
Valadares, K. 2004. “The Practicality of
Employee Empowerment: Supporting a
Psychologically Safe Culture.” Health Care
Manager 23: 220–24.
Yin, R. K. 2008. Case Study Research: Design and
Methods, 4th ed. Thousand Oaks, CA: Sage.
PRACTITIONER APPLICATION
Charles D. Stokes, BSN, MHA, FACHE, chief operating officer, Memorial Hermann
Healthcare System, Houston, Texas
W
hen healthcare leaders are asked why they got into healthcare, most respond
by saying they wanted to help people and make a difference. Frequently, CEOs
climbed the corporate ladder by starting their careers at the department director or
manager level, in which frequent interaction with hospital staff was essential for
them to be successful in career progression. Successful executives mastered their communication and engagement skills with the staff. They learned how to be approachable and motivational and how to hold their staff accountable for performance. A
common phenomenon is that the further executives progress in their leadership
responsibilities, the less feedback they receive about how they show up in the organization. Even those closest to the CEO are at times reluctant to give candid feedback
to the top executive for numerous reasons: fear for job security, allegiance to their
boss, and sometimes just being uncomfortable giving feedback. Many executives say
that at times, they feel very isolated at the top and unsure of how they are perceived
by governance, hospital, and medical staff.
In order for leaders to truly know what is going on in their organizations, they
must validate their feelings through feedback. CEOs and senior executives can no
longer delegate organizational culture development to directors and managers. They
must lead cultural transformation by developing a deep personal involvement with
hospital staff.
Clinical and financial excellence can only happen with an engaged workforce.
The following are several suggestions to improve employee engagement and therefore enhance organizational performance.
1.Weekly senior leadership rounding. Rounding should be required and documented for accountability.
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
147
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.
J o u r n al o f H ea l th c a re M a n a g em en t 5 7 : 2 M arc h / April 2012
2.“Ideas for Excellence” program. Leaders should actively solicit employees’
suggestions on how to improve organizational performance. When ideas are
implemented, leaders should reward and recognize these employees.
3.Employee recognition programs. Leaders should routinely recognize employees and medical staff at board meetings and monthly department meetings,
during senior leadership rounds, and through other hospital communication
tools. Personal handwritten thank-you notes are one of the most effective
forms of recognition. Senior leadership should send at least five handwritten
notes per week to hospital and medical staff.
4.Town hall meetings. Candid discussions about key organizational issues
around patient safety, clinical performance, and financial issues enhance
transparency and trust in leadership. Leaders recognize there are very few
“secrets” in the organization. Therefore, leaders should use the town hall
meetings to state the facts regarding issues and dispel rumors that are disruptive and detrimental to organizational culture.
5.A mandatory 360 evaluation process. Such evaluation processes should be
developed and implemented for all leaders in the organization. The evaluation elements should be tailored to be consistent with the organization’s
mission, vision, and values. This process should be completed annually for all
leaders, and when issues surface, the leader should be required to develop a
corrective action plan to address the feedback.
Most healthcare organizations have four to six strategic initiatives, critical success
factors, or pillars, usually articulated as people, physicians, service, quality, financial,
and growth. These are inextricably related to each other through leadership engagement. The formula for success goes like this: Engaged and motivated people and
physicians, delivering an exemplary level of service (patient satisfaction) and quality
(clinical outcomes) will produce sustainable financial results, which allows the organization continued growth.
It all starts with an engaged hospital and medical staff. Without an engaged and
self-aware leadership team, the first two initiatives, around people and physicians,
are difficult to achieve.
Photocopying or distributing this PDF
is prohibited without the permission of Health
Administration Press, Chicago, Illinois.
148
For permission, please contact the Copyright
Clearance Center at www.copyright.com.
For reprints, please contact HAP1@ache.org.